April 8, 2009

Older adults with generalized anxiety disorder who received cognitive behavior therapy had greater improvement on measures of worry, depression and mental health than patients who received usual care, according to a study in the April 8 issue of JAMA.

Generalized anxiety disorder (GAD) is common in late life, with prevalence up to 7.3 percent in the community and 11.2 percent in primary care. Late-life anxiety predicts increased physical disability, memory difficulties and decreased quality of life, according to background information in the article. Late-life anxiety is usually treated with medication, but associated risks (e.g., falls, hip fractures, memory problems) with some drugs and patient fears of adverse effects limit their usefulness. Two previous studies suggested benefits of cognitive behavior therapy (CBT) in primary care for late-life GAD, but the studies were small and the conclusions were limited. Older adults most often seek treatment for GAD in primary care.

Melinda A. Stanley, Ph.D., of the Baylor College of Medicine, Houston, and colleagues conducted the first randomized clinical trial of CBT for late-life GAD in primary care to examine whether CBT would improve outcomes relative to enhanced usual care (EUC). The trial included 134 older adults (average age, 67 years) in two primary care settings, with treatment provided for 3 months. Assessments were conducted at the beginning of the trial, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9, 12 and 15 months. Patients were randomized to either CBT (n = 70), which included education and awareness, relaxation training, cognitive therapy, problem-solving skills training and behavioral sleep management; or EUC (n = 64), in which patients were telephoned biweekly during the first 3 months of the study by the same therapists to provide support and ensure patient safety. Therapists reminded patients to call project staff if symptoms worsened.

Levels of anxiety, worry, depression and physical/mental health quality of life were measured via various tests or surveys. The researchers found that CBT, compared with EUC, significantly improved worry severity, depressive symptoms and general mental health. In intention-to-treat analyses, response rates defined according to worry severity were higher following CBT compared with EUC at 3 months (40.0 percent vs. 21.9 percent).

"This study is the first to suggest that CBT can be useful for managing worry and associated symptoms among older patients in primary care," the authors write. "This study paves the way for future research to test sustainable models of care in more demographically heterogeneous groups."